Insurance Coverage

I don't even remember what I've posted about anymore but I did want to mention this little tidbit.

Back last January (seems like a million years ago!) I was freaking out over the cost of IVF and with good reason - it's fucking scary! And don't think for an instant that it's ceased to be any less frightening just because I've gotten used to shelling out THOUSANDS of dollars to fertility clinics without batting so much as one single lash. I mean, at this point, if I am going to be suicidal over it, I might as well get out of the game, ya know? Sort of like going to a Mercedes dealership and having chest pains over the cost of upgrades vs. what you paid on your Corolla five years ago. You kind of develop brand new lenses by which to view it all or you'd go insane. (and, like, I'm not leaps and bounds away from that right now!)

So...back to my first IVF round (and only round - which turned into an IUI 'cause my eggs suck the big one and I have technically never had an IVF round - round #2 was a donor embryo cycle which resulted in a chemical pregnancy). Shit, I sound bitter. Oh well.....

When I plunked down nearly 12K for that round, I remember the finance person over the telephone telling me that they submit all of the charges to my insurance company and any reimbursement I receive will be returned to me. hee hee hee, I just chuckled 'cause you see, my insurance has NO INFERTILITY COVERAGE. But what did I care, if they made a mistake and cut me a check for 12K, I sure wasn't going to be Miss Honest and return it or anything wild and crazy like that. Besides, if they can pay for Viagra so some guy with a walker can get his boner going, I think contributing to the life of a baby is more than called for - but that's another
rant post.

Guess what arrived in my mailbox a few weeks later? Yeap, reimbursement for a saline sonogram (about 70% worth). I thought, okay, well, that wasn't "technically" the IVF, that was a test to ensure I didn't have some big ass polyp or fibroid in there like the one that had to be removed during the laprascopic surgery in June '07. But then something else happened, another reimbursement and another and another and another - all at around 70% for the ultrasounds and for the bloodwork, office visits, etc.

I thought, crap, how long will this last? Don't get me wrong, I signed the backs of those checks, hopped in my car and floored the gas pedal to the bank to deposit them at all hours - just in case they caught on. But would I have to reimburse big insurance company later - when they fired the nitwit who'd approved the claims? Would they take me to court? After all, I didn't submit the claims, the RE's office did - as a matter of protocol. I could just feign ignorance. In fact, I had my story all worked out and, actually, it wasn't far from the truth. It goes like this:

I didn't know if I had infertility coverage but I'd saved up enough for 1 IVF cycle. Since you guys sent me checks, I realized I must have insurance coverage so I signed up for more IVF cycles. Not only do I not owe you the money you sent to me but I will countersue you idiots - because of you, I got into extended fertility treatments when I could have been on the adoption trail only to have you pull out the rug from under me now when I'm too old to adopt (at 41). Yeah, okay, not great but it was my story.

Then came the "denied" claim. I got an Explanation of Benefits on my IUI ($300 for the insemination) and the denial explanation was that infertility coverage is not part of my plan. WTF?! Hey, assholes, you've been paying claims from a doctor's office whose name leaves NO DOUBT whatsoever that it's an infertility center and you're onto it now?

But as long as they didn't come after me for the thousands reimbursed up to that point, I was super happy. Next claim for blood work, paid again. Huh? I guess the nitwit insurance processor was on vacation so they rightly denied my insemination claim but thank-my-lucky-stars she's back and now they're paying again. Woo Hoo!

Fast forward to donor embryo frozen transfer. I was at the 3K out of pocket maximum for the year even though they'd been covering 70% thus far and for that cycle, I was reimbursed 100% of nearly all services. Holy shit! Again, I laid low, cashed the checks and kept my passport handy in case I had to flee from the cops when I was busted for this major heist.

Then came CCRM - Oh, this one's big. They charge a fortune - I mean, the place is beautiful and rivals a high-end spa. There is a lovely water feature in the lobby and the location is pretty stunning. Surely big insurance company is going to bust me now. This is just plain asking for it. But what could I do - they hold the #1 spot in the country, likely the world. I have no choice - this time there will be no reimbursement.

Guess what the finance person said to me right before the 1-day workup? That they take my insurance (Huh? Who cares lady 'cause my insurance doesn't pay for fertility treatments) and that the approximately $2,300 bill for the day's tests will likely be paid by them. Okay. Sure enough, got my Explanation of Benefits - they paid (a smaller, contracted rate with CCRM, but they paid). And since then the CCRM finance person told me that she spoke with my insurance company. Ugh! I wanted to yell at her "WHY are you killing my mojo?! What have I ever done to you!" when she said "your policy doesn't include IVF but includes all of the ultrasounds and bloodwork."

WHAT?! Well, then it all made sense for certain. I thought the ONLY way these reimbursements all year long were legit was something funky like this and WEEEEEEEE, that's what it is!

So check out how bizarre this is. An IVF cycle is 12K plus 4K in meds. My insurance company won't pay the meds so that's 4K out of pocket. And they won't pay for assisted hatching or ICSI or anything related to the egg. But they'll pay for all of the ultrasounds and blood work which as you ladies know is an ENORMOUS part of IVF. So about 7K (out of 16K) will be reimbursed to you. Okay, that's less than half but it's still a WHOLE LOT more than zero reimbursement.

I don't know what's going to happen with my donor egg cycle. I know I have to write CCRM a check for 29K when the cycle begins. Seriously, I just chuckled sarcastically over it - the number is STAGGERING - I could buy a brand new SUV outright, with bells and whistles!

But I think I might start getting reimbursement checks from big insurance company as soon as my cycle starts ringing in the fees. If I get even 5K back, I'll be THRILLED!

Big smiles over surprise gift this year!


Me said...

I hate you. I have a small business and pay approx $600 per month for health insurance. But they've never paid one single penny for IF treatments. (Though they did admittedly cover my HSG and lap as those were coded as being related to my PCOS and not IF.)

Sky said...

Oh my little atheist friend, I know, I know. Listen, I am HOT about the fact that IF isn't covered completely by insurers. I mean, Viagra yes but IF no? What kind of insanity is that?!

About my own coverage, I almost hate me too - I can't believe how fortunate I was to have ANY reimbursement.

I remember telling this (the lucky reimbursement structure) to a friend of mine who said "yeah, but it's not for assisted hatching and inseminations" and I said "you've clearly never paid for IF treatment or you'd know that ultrasounds, related office visits and bloodwork are an ENORMOUS part of the cost."

I hope your insurance provider changes their tune on you too! :)

Miss Tori said...

Thanks for stopping by my blog. I was going to go to CCRM, however, they are not part of my insurance network, and it will only reimburse/pay for ART procedures done by in network providers.

Now I am considering Dr. Swanson, who is part of my network. I'll give him a shot after the first of the year with my eggs. If that doesn't work, then I'll proceed with the donor eggs. I'll be paying OOP for the egg part of it, although my expenses will be covered.

I'm pretty fortunate that my employer is based out of a state that mandates IF coverage. It isn't a lot ($10k lifetime), however, none of the b/w, u/s, meds have applied to the $10k. I guess only the actual ER, ET, ICSI applies to that, and since I never made it that far, I've not used up any of my maximum benefit.

When we were deciding what to do, we were comparing $25k OOP with CCRM with low chance of success versus $13k OOP with donor eggs with higher chance. That's why we decided against CCRM. But now that I've found out about Dr. Swanson via a blogger friend, I'm going to see if he can help out. Maybe he can get my eggs to respond.

Sorry for the short novel!

Sky said...

Miss Tori, congrats on being covered for IVF. I'm also in a mandated state (NJ) BUT there are a hundred loop holes that occur - my company is HUGE (over 50K employees) and, yet, IVF is not covered (but b/w and ultrasounds are . . . so I'm very grateful for that).

Best of luck with donor eggs - yes, excellent chances there!